Concussion Patients Research Articles

Management of Traumatic Brain Injuries with Brain Concussion – A Review

A typical occurrence in emergency rooms is traumatic brain injury (TBI) resulting from head trauma which is normally responsible for far more than 1 million visits per year. The magnitude of TBIs varies from mild, intermittent symptoms to longer periods of altered states of consciousness. The precise mechanism of concussion is indefinite. In serious brain trauma, Axon tearing is expected, but there is no evidence for this concussion process. Most concussion patients improve rapidly and entirely. Concussion management is usually supportive and some cases may need hospital admissions and ICU care according to severity of injury and related symptoms.

Diffusion tensor tractography characteristics of axonal injury in concussion/mild traumatic brain injury.

The main advantage of diffusion tensor tractography is that it allows the entire neural tract to be evaluated. In addition, configurational analysis of reconstructed neural tracts can indicate abnormalities such as tearing, narrowing, or discontinuations, which have been used to identify axonal injury of neural tracts in concussion patients. This review focuses on the characteristic features of axonal injury in concussion or mild traumatic brain injury (mTBI) patients through the use of diffusion tensor tractography. Axonal injury in concussion (mTBI) patients is characterized by their occurrence in long neural tracts and multiple injuries, and these characteristics are common in patients with diffuse axonal injury and in concussion (mTBI) patients with axonal injury. However, the discontinuation of the corticospinal tract is mostly observed in diffuse axonal injury, and partial tearing and narrowing in the subcortical white matter are frequently observed in concussion (mTBI) patients with axonal injury. This difference appears to be attributed to the observation that axonal injury in concussion (mTBI) patients is the result of weaker forces than those producing diffuse axonal injuries. In addition, regarding the fornix, in diffuse axonal injury, discontinuation of the fornical crus has been frequently reported, but in concussion (mTBI) patients, many collateral branches form in the fornix in addition to these findings in many case studies. It is presumed that the impact on the brain in TBI is relatively weaker than that in diffuse axonal injury, and that the formation of collateral branches occurs during the fornix recovery process. Although the occurrence of axonal injury in multiple areas of the brain is an important feature of diffuse axonal injury, case studies in concussion (mTBI) have shown that axonal injury occurs in multiple neural tracts. Because axonal injury lesions in mTBI patients may persist for approximately 10 years after injury onset, the characteristics of axonal injury in concussion (mTBI) patients, which are reviewed and categorized in this review, are expected to serve as useful supplementary information in the diagnosis of axonal injury in concussion (mTBI) patients.

Exploring Vestibular/Ocular and Cognitive Dysfunction as Prognostic Factors for Protracted Recovery in Sports-Related Concussion Patients Aged 8 to 12 Years.

To explore the prognostic ability of the vestibular/ocular motor screening (VOMS), King-Devick (K-D) Test, and C3 Logix Trails A and B to identify protracted recovery from sports-related concussion (SRC) in patients aged 8 to 12 years. Retrospective cohort analysis. Specialty pediatric sports concussion clinic. A total of 114 youth athletes aged 8 to 12 years who were diagnosed with an SRC within 7 days of injury. A positive screen on the VOMS, K-D, and C3 Logix Trails A and Trails B. Combined positive screens on multiple tests (ie, 2, 3, or all 4 positive screens of 4 possible). Recovery time in days and protracted recovery (recovery time ≥30-days) were the primary outcomes of interest. A positive VOMS screen was associated with 1.31 greater days to SRC recovery ( P = 0.02) than a negative VOMS screen. The K-D and C3 Logix tests were not significantly associated with recovery time, nor were any combinations of tests ( P > 0.05). The VOMS demonstrated moderate prognostic ability to predict normal recovery (negative predictive value = 80.78% [95% CI = 63.73-90.95]). Overall predictive accuracy of normal versus protracted recovery was strongest when a participant screened positive on all 4 tests (Accuracy = 76.32% [95% CI = 67.45-83.78]). The VOMS was associated with overall recovery time and proved to be a useful test to identify those who would experience a normal recovery time. Combining the 4 tests improved the prognostic accuracy of the protocol in predicting protracted versus normal recovery. These findings suggest that combining multiple, varied assessments of cognition and vestibular/ocular functions may better explain factors contributing to protracted recovery.

The Effect of Aerobic Exercise on Concussion Recovery: A Pilot Clinical Trial.

The purpose of this study was to pilot safety and tolerability of a 1-week aerobic exercise program during the post-acute phase of concussion (14-25 days post-injury) by examining adherence, symptom response, and key functional outcomes (e.g., cognition, mood, sleep, postural stability, and neurocognitive performance) in young adults. A randomized, non-blinded pilot clinical trial was performed to compare the effects of aerobic versus non-aerobic exercise (placebo) in concussion patients. The study enrolled three groups: 1) patients with concussion/mild traumatic brain injury (mTBI) randomized to an aerobic exercise intervention performed daily for 1-week, 2) patients with concussion/mTBI randomized to a non-aerobic (stretching and calisthenics) exercise program performed daily for 1-week, and 3) non-injured, no intervention reference group. Mixed-model analysis of variance results indicated a significant decrease in symptom severity scores from pre- to post-intervention (mean difference = -7.44, 95% CI [-12.37, -2.20]) for both concussion groups. However, the pre- to post-change was not different between groups. Secondary outcomes all showed improvements by post-intervention, but no differences in trajectory between the groups. By three months post-injury, all outcomes in the concussion groups were within ranges of the non-injured reference group. Results from this study indicate that the feasibility and tolerability of administering aerobic exercise via stationary cycling in the post-acute time frame following post-concussion (14-25 days) period are tentatively favorable. Aerobic exercise does not appear to negatively impact recovery trajectories of neurobehavioral outcomes; however, tolerability may be poorer for patients with high symptom burden.

Neuromuscular training after concussion to improve motor and psychosocial outcomes: A feasibility trial

ObjectiveTo determine the feasibility of an 8-week neuromuscular training program initiated upon return-to-play clearance following concussion. DesignFeasibility trial. SettingA single sports medicine center. ParticipantsWe approached n = 54 patients; n = 32 agreed to participate (59%). N = 27 participants returned for their second visit at return-to-play clearance (84%) and were randomized to neuromuscular training (n = 13) or standard-of-care (n = 14). Main outcome measuresParticipants completed three assessments: within 14 days post-concussion, immediately after return-to-play clearance, and 8-weeks following return-to-play clearance. The intervention aimed to achieve positive neuromuscular adaptations and occurred 2x/week for 8 weeks under supervision. ResultsN = 2 participants randomized to the intervention elected not to participate, both due to schedule conflicts (e.g., time required to meet with the study team). Participants began the intervention an average of 11 days after return-to-play clearance, the majority (91%) completed >75% of training sessions, and training sessions lasted an average of 18.2 ± 4.8 min. One participant stopped the intervention after 7 training sessions due to time availability. ConclusionIt is feasible to initiate a neuromuscular training program for most athletes shortly after returning to play following concussion. Clinicians and researchers may consider this approach to mitigate the increased musculoskeletal injury risk for concussion patients returning to sports.

Neurocognitive correlates of persisting concussion symptoms in youth

Many patients that experience a concussion have impairing symptoms that persist beyond typical recovery timeframes. Concussion symptoms often remit within a month, but persisting impairments are difficult to characterize and attribute to concussion given the poorly defined diagnostic criteria of post-concussion syndrome and inadequate understanding of the cognitive symptoms associated with this condition. The current study aims to clarify the cognitive profiles of school-aged concussion patients (n = 21; N = 36; 64% male) that have persisting symptoms to improve the clinical identification methods for this condition. Logistic regression was used to explore the importance of cognitive processing speed and working memory for identifying patients with persisting concussion symptoms (PCS). Additional exploratory analyses were conducted to clarify cognitive domains that may be impacted by having PCS. Findings indicate processing speed and working memory abilities alone are not adequate to identify patients with PCS. Further, measures of processing speed, fluid reasoning, working memory, and long-term retrieval together were found to be necessary to identify those who had a prior concussion with PCS. These findings indicate clinical neuropsychological batteries must include measures of these four cognitive domains when assessing school-aged patients with chronic symptoms that extend beyond three months following injury.

Post-concussion Dizziness, Sleep Quality, And Postural Stability In Young Athletes

PURPOSE: Dizziness is a common post-concussion symptom. We examined associations among dizziness, sleep quality, and postural stability for pediatric athletes with concussion. METHODS: We evaluated patients ages 10-18 years within 14 days of concussion (n = 58, 15.2 + 1.8 years; 50% female; 7.1 + 3.1 days post-injury) and compared them to healthy controls (n = 73; 15.8 + 1.3 years; 42% female). Patients completed ratings of pre-injury and current dizziness (Post-Concussion Symptom Inventory [PCSI]) and current sleep quality (Pittsburgh Sleep Quality Index [PSQI]). Trained research assistants administered postural stability assessments (single/dual-task tandem gait [TG] and modified Balance Error Scoring System [mBESS]). We grouped concussion patients based on the difference between their current and pre-injury dizziness ratings: difference > 3 = dizzy (n = 21); difference < 2 = not dizzy (n = 37). RESULTS: The dizzy group reported significantly worse sleep quality than the not dizzy and control groups. However, the not dizzy group still reported significantly worse sleep ratings than healthy controls (mean = 9.6 + 3.7 vs 7.2 + 3.5 vs 4.3 + 2.6; p < 0.001). Similarly, the dizzy group performed the slowest on single and dual-task TG, followed by the not dizzy group, then the control group (single-task TG: mean = 27.2 + 11.7 sec vs 21.2 + 6.3 vs 14.7 + 3.6; p < 0.001); (dual-task TG: mean = 38.4 + 16.2 sec vs 29.9 + 7.2 vs 21.6 + 7.5; p < 0.001). The dizzy group demonstrated more mBESS errors than the other two groups, while the not dizzy group demonstrated more errors than the control group (mean = 9.8 + 5.1 vs 6.9 + 5.8 vs 3.8 + 3.5; p < 0.001). Differences in mBESS scores between concussion groups were not significant (p = 0.055). CONCLUSION: Worsening dizziness post-concussion was associated with impaired sleep quality and TG. Sleep quality and TG measures differed between dizzy and not-dizzy concussion groups, while mBESS scores did not. Thus, when evaluating patients with post-concussion dizziness, measures of sleep quality and postural control, specifically TG, may provide clinicians with clinically useful information. Although limited, our data suggest that worsened dizziness post-concussion may play a role in the sleep and postural stability impairments identified in the concussion literature.

Orthostatic intolerance in post-concussion patients

ABSTRACT Orthostatic intolerance (OI) following pediatric concussion is not well understood. Assessing the prevalence of concussion-related OI and how it compares to non-concussion-related OI will improve care for patients suffering with these symptoms. OBJECTIVE: We set out to describe concussion-related OI in adolescence, with particular emphasis on time to recovery and differences from non-concussion-related OI (including male vs. female prevalence). Retrospective chart reviews were completed on post-concussion patients endorsing symptoms of OI. The patients’ sex, sport history, previous concussions, time since injury, and recovery time were analyzed and compared between males and females as well as against general OI statistics. Thirty-nine pediatric patients, representing 8.7% of all new patients referred to a specialized concussion clinic over a 13-month interval, were included in the chart review. Mean age of onset was 15.0 ± 2.5 years and 18 (46%) were males. The median times from evaluation to symptom resolution were 120 days. Of 18 patients who completed head-up tilt table testing, 17 (94%) had orthostatic tachycardic response (>40 bpm heart rate increment). Post-concussive OI differs from other orthostatic intolerance etiologies, lacking a strong female predominance and exhibiting a shorter time course to recovery compared to other etiologies of OI (but longer recovery time compared to concussion patients in general). Clinical orthostatic vital signs may not be sensitive for diagnosing orthostatic intolerance in athletes, likely due to higher vagal tone and more efficient skeletal muscle pump.

CHANGES IN DUAL-TASK GAIT VELOCITY COST FOLLOWING CONCUSSION

Background:Changes in gait velocity have been identified in the literature between concussed and non-concussed individuals. Concussed patients demonstrate slower gait speed; the gait velocity cost has not been evaluated as extensively.Hypothesis:Hypothesis 1: Dual-task gait velocity cost will decrease at time of clearance compared to initial testing.Hypothesis 2: Subjects with a SRC will demonstrate greater decreases in gait velocity costs than those with non-SRC.Hypothesis 3: Symptom severity will be positively correlated to dual-task gait costs within the first 5 days after concussion.Methods:Patients evaluated for concussion in primary care sports medicine clinic within five days of injury were recruited between October 2017 and May 2019. The mechanism of injury was documented and used to classify sport-related (SRC) versus non sport-related (non-SRC) concussion. A standard concussion evaluation was performed at each visit to assess history, symptoms, neurocognitive, neuromuscular and vestibular dysfunction. Dual-task walking trials were incorporated with a cognitive task such as reciting the months of the year in reverse order or spelling words backwards. During the walking trials, gait velocity was measured using an Xsens MVN BIOMCH system (Xsens Technologies BV, Enschede, The Netherlands). A two-way mixed ANOVA with one within-subjects factor (time) and one between-groups factor (mechanism of injury) was used to determine if dual-task gait velocity costs differed over time and between those with a SRC versus those with a non-SRC. A Pearson’s product-moment correlation was used to assess the relationship between symptom severity scores and dual-task gait costs at initial visit.Results:There was no statistically significant interaction between the mechanism of injury and time on gait velocity cost, F(1, 79) = .033, p = .86. The main effect of time showed a statistically significant difference in mean gait velocity cost from initial to clearance, F(1, 79) = 6.19, p = 0.015, generalized η2 = .0.013. There was no main effect of mechanism of injury in mean gait velocity costs, F(1, 79) = 0.800, p = 0.374, generalized η2 = 0.008.There was a statistically significant, small positive correlation between symptom severity and dual-task gait velocity costs, r = .30, p < .007, with symptom severity explaining 9 % of the variation in dual-task gait velocity costs.Conclusion:The gait velocity cost demonstrates a statistically significant change from the time of injury to clearance in concussion patients. A small but significant relationship also exists between symptom severity and gait velocity cost.

IS NEAR POINT OF CONVERGENCE ASSOCIATED WITH SYMPTOM PROFILES OR RECOVERY IN ADOLESCENTS AFTER CONCUSSION?

Background:Visual impairments, including oculomotor impairments, are common following concussion. Accurate, efficient, and objective measurement of post-concussion visual impairments may help guide treatment pathways. Less is known about how specific concussion symptoms are associated with visual impairments.Hypothesis/Purpose:Our purpose was to compare the clinical and injury characteristics of concussion patients who demonstrated receded near point of convergence (NPC) (defined as measurement >6 cm using accommodation rule from bridge of nose) to those with normal NPC (≤6 cm). We hypothesize that patients demonstrating receded NPC would show greater symptom burden and have longer recovery when compared to those with normal NPC.Methods:Concussion patients who were seen within 14 days of injury were included. We performed univariable demographic, injury, and clinical characteristic comparisons between those with and without receded NPC break point using independent samples t-tests and Chi-square analyses. We compared NPC break point between those who did not recover within 28 days of injury (PPCS; persistent post-concussion symptoms) and those who did (no PPCS). A multivariable linear regression model was constructed to identify which factors were associated with NPC break point distance.Results:We evaluated 123 patients using a multimodal concussion evaluation within 14 days of injury. Those with receded NPC (n=77) were significantly younger than those with normal NPC (n=46; Table 1). The receded NPC group had a significantly greater proportion of patients reporting headaches at initial assessment, as well as significantly greater overall, cognitive and somatic symptom severity (Table 2). The group who went onto experience PPCS had a significantly greater NPC at initial evaluation than those without PPCS (p=0.02; Figure 1). The receded NPC group committed more modified Balance Error Scoring System (mBESS) errors than the normal NPC group, but there were no significant differences for tandem gait test performance (Table 3). In our multivariable model, we observed that among all potential predictor variables, more severe somatic symptoms were significantly associated with a greater NPC (Table 4).Conclusion:Those with receded NPC at initial evaluation showed an increased symptom burden, most notable with somatic symptoms, compared with those without receded NPC. Additionally, we were able to elucidate that those who went on to develop PPCS had greater NPC than those recovered within 28 days. Visual disorders may be an important driver of symptom profiles following concussion in adolescents. The impact of visual disturbance treatment following concussion in adolescents on symptom resolution should be further evaluated.Tables/Figure:Figure 1.Individual data points describing the distribution of NPC break points (cm) between patients who required >28 days for concussion symptom resolution (PPCS) and those who recovered within 28 days (No PPCS). The black bar represents the mean group value. The PPCS group had a significantly greater mean NPC break point than the No PPCS group (p=0.02).

Recent Preoperative Concussion and Postoperative Complications: A Retrospective Matched-cohort Study.

Physiological alterations during the perianesthetic period may contribute to secondary neurocognitive injury after a concussion. Patients exposed to concussion and who received an anesthetic within 90 days were matched to unexposed patients without concussion. Intraoperative and postoperative events were compared. Subgroup analyses assessed relationships among patients with a concussion in the prior 30, 31 to 60, and 61 to 90 days and their respective unexposed matches. To facilitate identification of potential targets for further investigation, statistical comparisons are reported before, as well as after, correction for multiple comparisons. Sixty concussion patients were matched to 176 unexposed patients. Before correction, 28.3% postconcussion versus 14.8% unexposed patients reported postanesthesia care unit pain score≥7 (P=0.02); 16.7% concussion versus 6.5% unexposed patients reported headache within 90 days of anesthesia (P=0.02) and 23.5% of patients who received surgery and anesthesia within 30 days of concussion experienced headache within 90 days of anesthesia compared with 7.1% in the unexposed group (P=0.01). Patients who experienced concussion and had anesthesia between 31 and 60 days after injury had a postanesthesia care unit Richmond Agitation and Sedation Scale score of -1.61±1.29 versus a score of -0.2±0.45 in unexposed patients (P=0.002). After adjusting the P-value threshold for multiple comparisons, the P-value for significance was instead 0.0016 for the overall cohort. Our study revealed no significant associations with application of adjusted significance thresholds. There were no differences in intraoperative and postoperative outcomes in patients with recent concussion compared with unexposed patients. Before correction for multiple comparisons, several potential targets for further investigation are identified. Well-powered studies are warranted.

THE CLINICAL UTILITY OF THE VESTIBULAR AND OCULAR MOTOR SCREENING FOR PROTRACTED RECOVERY IN PEDIATRIC CONCUSSION PATIENTS

Background:Sports-related concussions (SRCs) are a concern for youth athletes and their subsequent healthy development into adulthood. Protracted recovery (>28 days) from a SRC may lead to long-term complications resultant of persistent symptoms. There is a current lack in understanding of the factors contributing to protracted recovery from SRC in children, and in particular no tools exist to identify those SRC patients that may be more likely have a protracted recovery in an acute clinical setting.Hypothesis/Purpose:To examine the relationship between initial Vestibular and Ocular Motor Screening (VOMS) and protracted recovery from concussion in youth.Methods:Children aged 8-12 years old, who were diagnosed with a SRC and seen in a concussion specialty clinic within 7-days of injury were included in the analysis. VOMS was administered during the initial visit. A positive VOMS score was defined as any 2-point increase from baseline in patient reported symptom severity on dizziness, fogginess, headache, and nausea, or any convergence measure greater than 6 centimeters. Recovery time (days) was the interval between date of injury and date of medical clearance. Multivariable logistic regressions were used to determine the odds of protracted recovery based on an initial positive VOMS.Results:A total of 108 males (mean age=10.8, sd=1.3) and 66 females (mean age=10.8, sd=1.4), took a median (IQR) 20.0 (15.0-28.5) and 22.0 (15.0-34.0) days to recover, respectively. After controlling for age and days since injury, those with a positive VOMS were 3.92 (95% CI = 1.58-9.71, p=0.003) times more likely to have a protracted recovery compared to those with a negative VOMS. When stratified by sex, observed effects were more amplified among males (OR=5.92, 95% CI=1.59-21.96, p=0.008), than among females (OR=2.44, 95% CI=0.61-9.71, p=0.21).Conclusion:There is a need to determine the relationship between SRC assessment measures and recovery time to improve clinical management and outcomes. In this sample of pediatric concussion patients aged 8-12 years, the VOMS displayed potential as a tool to screen for delayed recovery among males. Future studies should confirm these findings in other, larger samples, while taking into consideration other factors that may influence recovery time.

Is Overparenting Associated with Adolescent/Young Adult Emotional Functioning and Clinical Outcomes Following Concussion?

Overparenting(O-P), or "helicopter" parenting, has warranted increased attention across the past decade. It is characterized as being overly involved, protective, and low on granting autonomy, and is associated with deleterious psychosocial outcomes outside of the concussion literature. This study examined the association of overparenting and patient emotional distress and clinical outcomes (i.e., symptoms, neurocognitive test scores, recovery time) post-concussion. Adolescents/young adult concussion patients (injury < 30days) and parents (N = 101 child-parent dyads) participated. Patient participants completed measures of depression, anxiety, stress, and concussion clinical outcomes while parents concurrently completed an overparenting measure. Results of a general linear model found that overparenting was associated with higher anxiety and stress report of the child. Overparenting had a significant positive correlation with concussion recovery, although of a small magnitude. Emotional distress level, but not overparenting, was moderately associated with worse performance on clinical outcomes, including neurocognitive testing, vestibular/ocular motor dysfunction, and concussion symptom severity.

Localization and Identification of Brain Microstructural Abnormalities in Paediatric Concussion.

In the United States, approximately 2.53 million people sustain a concussion each year. Relative to adults, youth show greater cognitive deficits following concussion and a longer recovery. An accurate and reliable imaging method is needed to determine injury severity and symptom resolution. The primary objective of this study was to characterize concussions with diffusion tensor imaging (DTI). This was performed through a normative Z-scoring analysis of DTI metrics, fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD), to quantify patient-specific injuries and identify commonly damaged brain regions in paediatric concussion patients relative to healthy controls. It was hypothesized that personalizing the detection analysis through normative Z-scoring would provide an understanding of trauma-induced microstructural damage. Concussion patients were volunteers recruited from the Emergency Department of the McMaster Children’s Hospital with a recent concussion (n = 26), 9 males and 17 females, mean age 14.22 ± 2.64, while healthy paediatric brain DTI datasets (25 males and 24 females, mean age 13.52 ± 1.03) were obtained from an MRI data repository. Significant abnormalities were commonly found in the longitudinal fasciculus, fronto-occipital fasciculus, and corticospinal tract, while unique abnormalities were localized in a number of other areas reflecting the individuality of each child’s injury. Total injury burden, determined by the number of regions containing outliers per DTI metric per patient, was used as the metric to quantify the overall injury severity of each patient. The primary outcome of this analysis found that younger patients experienced a significantly greater injury burden when measured using fractional anisotropy (p < 0.001). These results show that DTI was able to detect microstructural changes caused by concussion, on a per-person basis, and has the potential to be a useful tool for improving diagnostic accuracy and prognosis of a concussion.

A - 24 Exploring Vestibular/Ocular and Cognitive Dysfunction as Prognostic Factors for Protracted Recovery in Sports-Related Concussion Patients Aged 8–12 Years

Abstract Objective To explore the prognostic ability of the Vestibular/Ocular Motor Screening (VOMS) tool, the King-Devick Test (KD), and the C3 Logix Trails A and B (C3), individually and in combination, for identifying protracted recovery from sports-related concussion (SRC) in patients aged 8–12 years. Methods 114 youth athletes aged 8–12 years diagnosed with a SRC within 7-days of injury participated in this study. The prognostic ability of the VOMS, KD, and C3 to classify patients as normal versus protracted recovery, defined as recovery time greater than 30-days, was evaluated using measures of test validity and predictive ability. Results After adjustment for age and days since injury, a positive VOMS was associated with 1.31 greater days to recover (p = 0.02) than a negative VOMS. The KD, and the C3 were not significantly associated with recovery time (all p &amp;gt; 0.05), nor were any combinations of tests (any 2 or 3 positive tests, all 4 positive tests). The VOMS prognostic ability to predict normal recovery (NPV = 80.78% [95%CI = 63.73–90.95]) was moderate. Overall predictive accuracy of normal versus protracted recovery was strongest when a participant screened positive on 3 out of 4 possible measures (Acc = 66.67% [95%CI = 57.23–75.22]). Conclusions The VOMS was the most useful test for identifying patients who will experience a normal SRC recovery time, however, combining the VOMS with KD and C3 improved prognostic accuracy. These findings suggest that combining multiple, varied assessments of cognition and vestibular/ocular functions may be useful for understanding factors contributing to protracted recovery from SRC.

Clinical Outcomes of Pediatric Acute Sport- and Non-Sport-Related Concussions.

The objectives were to examine clinical characteristics, length of recovery, and the prevalence of delayed physician-documented recovery, compare clinical outcomes among those with sport-related concussion (SRC) and non-sport-related concussion (nSRC), and identify risk factors for delayed recovery. Included patients (8-18 years) were assessed ≤14 days post-injury at a multidisciplinary concussion program and diagnosed with an acute SRC or nSRC. Physician-documented clinical recovery was defined as returning to pre-injury symptom status, attending full-time school without symptoms, completing Return-to-Sport strategy as needed, and normal physical examination. Delayed physician-documented recovery was defined as >28 days post-injury. Four hundred and fifteen patients were included (77.8% SRC). There was no difference in loss of consciousness (SRC: 9.9% vs nSRC: 13.0%, p = 0.39) or post-traumatic amnesia (SRC: 24.1% vs SRC: 31.5%, p = 0.15) at the time of injury or any differences in median Post-Concussion Symptom Scale scores (SRC: 20 vs nSRC: 23, p = 0.15) at initial assessment. Among those with complete clinical follow-up, the median physician-documented clinical recovery was 20 days (SRC: 19 vs nSRC: 23; p = 0.37). There was no difference in the proportion of patients who developed delayed physician-documented recovery (SRC: 27.7% vs nSRC: 36.1%; p = 0.19). Higher initial symptom score increased the risk of delayed physician-documented recovery (IRR: 1.39; 95% CI: 1.29, 1.49). Greater material deprivation and social deprivation were associated with an increased risk of delayed physician-documented recovery. Most pediatric concussion patients who undergo early medical assessment and complete follow-up appear to make a complete clinical recovery within 4 weeks, regardless of mechanism.

Is near point of convergence associated with symptom profiles or recovery in adolescents after concussion?

Our purpose was to compare the clinical and injury characteristics of concussion patients with a receded near point of convergence (NPC) vs those without a receded NPC. Concussion patients were seen within 14 days of injury. We compared those with receded a NPC (>6 cm) break point distance and those with a normal NPC distance on symptom, behavioral, and clinical assessments. We also compared NPC break points between those who did/did not recover within 28 days of injury. 123 patients completed the assessment. 77/123 (63%) of participants demonstrated a receded NPC when tested within 14 days of injury. Those with receded a NPC break point (n = 77; mean = 14.9, SD = 1.5 years; 47% female) were significantly younger than those with a normal NPC break point (n = 46; mean = 15.7, SD = 1.7 years; 46% female). The receded NPC break point group had a significantly greater proportion of patients reporting headaches (86% vs. 61%), as well as significantly greater cognitive (mean = 13.4, SD = 8.7 vs. mean = 8.8, SD = 8.6), somatic (mean = 10.0, SD = 5.9 vs. mean = 6.9, SD = 6.6), and overall (mean = 23.7, SD = 13.6 vs. mean = 15.8, SD = 14.4) symptom severity. Our multivariable model indicated among all potential predictor variables, more severe somatic symptoms were significantly associated with a greater NPC break point (β = 0.26; 95% CI = 0.01, 0.52). The group who went onto experience persistent symptoms had a significantly greater NPC break point at initial evaluation than those without persistent symptoms (mean = 9.7, SD = 7.5 cm vs. mean = 7.0, SD = 4.0 cm). Those with a receded NPC break point at initial evaluation showed an increased symptom burden, most notable with somatic symptoms, compared with those without a receded NPC break point.

The Influence of Timing of Reporting and Clinic Presentation on Concussion Recovery Outcomes: A Systematic Review and Meta-Analysis

Identifying risk factors for prolonged recovery following concussion can assist clinicians with appropriate management strategies. It is thought that athletes who continue to participate following a hit to the head or body may take longer to recover following a concussion diagnosis. To systematically review the body of literature regarding the effect of delayed reporting and delayed presentation to medical providers on concussion recovery times. Systematic review with meta-analysis. PubMed, Ovid Medline, SPORTDiscus, Cochrane Central Register of Controlled Trials and hand searches of reference lists. All the searches were performed in April 2020. Studies included an investigation of immediate versus delayed reporting or early versus late presentation following a concussion, were published in the past ten years, and were level 4 evidence or higher. 12 studies were included. Patients who continued play or delayed reporting their concussion had significantly longer recovery times (standardized mean difference = 0.36 days (95%CI 0.066, 0.662) than those who immediately reported or were removed from play (p = 0.017). Expressed in raw scores, those who immediately reported recovered in 5.4 days (95% CI − 10.14, − 0.75) fewer than delayed reporters. Comparable results were found for post-concussion symptom scores (p = 0.034) with immediate reporters demonstrating lower symptom severity scores. Our qualitative synthesis found patients who presented earlier to a concussion specialist tended to recover faster than those who presented later. Patients who delayed reporting or continued play had longer recovery times compared to their immediately-reporting peers. Providers should ask concussion patients approximately how long they waited to report their injury, and also focus educational efforts on encouraging immediate reporting of concussion.

Using the PHQ-9 to identify and manage depressive symptoms in patients with sport-related concussion.

Concussion patients might present with different constellations of symptoms, making management challenging. Two recent cases of college students, one with suicidal thoughts and one with panic attack, demonstrate how important it is to identify serious mental health issues associated with

Association of Chiropractic Colleges Research Agenda Conference 2021 Abstracts of Proceedings.

Association of Chiropractic Colleges Research Agenda Conference 2021 Abstracts of Proceedings.